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IN THE NAME OF

The Most Beneficent


&
The Most Merciful
THE ROLE OF MAGNESIUM SULPHATE IN
THE MANAGEMENT OF ACUTE ASTHMA

By

DR. COLONEL (R) AZMAT ALI


M.B.B.S, MSc. (Medical Administration)

DEPARTMENT OF PHARMACOLOGY

ISRA UNIVERSITY
HYDERABAD, SINDH
1. INTRODUCTION

• Mg Sulphate, an additive in the management of acute


asthma
• It may be effective through a variety of mechanisms
• It is a common mineral in geological strata
• Its other uses are
• Magnesium may play a role in the pathogenesis of
asthma.
• Intravenous magnesium may be helpful when
conventional therapy fails
2. AIMS AND OBJECTIVES

• To determine the substantial evidence regarding the


role of MgSO4 in acute asthma.

• To determine whether this may be supportive therapy


for patients presenting to the emergency department
with acute asthma.
3. RATIONALE OF STUDY

In acute severe asthma, patients are extremely


distressed, using accessory muscles of
respiration, are hyperinflated and tachypnoeic,
ultimately exhausted and require ventrilatory
support.
Therefore aim of study is to prevent such a
grave situation to develop by timely
administration of intravenous or inhalation of
magnesium sulphate.
4. MATERIALS AND METHODS:

4.1. Study design:


Descriptive comparative
4.2. Setting:
Department of Medicine, Isra University
Hospital, Hyderabad, Liaquat University
Hospital, Jamshoro and Institute of Chest
Diseases, Kotri
4.3. Duration of study:
Six months from January 2010 to June 2010
4.4. Sample size:

73 patients of acute asthma were enrolled in this study.

Group I:
Patients were administered oxygen, intravenoushydrocortisone
and nebulization with ventoline solution

Group II:
Patients were administered intravenous magnesium sulfate besides
oxygen administration, parenteral Hydrocortisone and
nebulization by ventoline solution
4.5. Sampling technique:
Non Probability Sampling
4.6. Sample Selection:
4.6.1. Inclusion criteria:
1. Hospitalized patients with acute asthma between
the ages of 10 to 40 years.
2. Patients having Peak Expiratory Flow Rate is >
50 %.
3. Those who give informed consent
4.6.2. Exclusion criteria:
1. Congestive cardiac failure
2. Coronary artery disease
3. Diabetes mellitus
4. Renal insufficiency
5. Hypertension
6. Pnemonaemias
7. Pregnancy
8. Patients with temperature > 39.8OC
9. Patients who are unable to use expiratory flow meter.
4.7.1. Sample collection (investigations)

Patient’s samples were collected:

Blood by Venepuncture into EDTA tube (2 ml for Blood CP)


2. 2 ml blood for sugar in fluoride bottle
3. 2 ml of blood in plain bottle for serum magnesium
4. 2 ml of blood in heprinized syringe for ABGs
5. Urine DR and for pregnancy test in case of females

4.7.2. Sample preparation

The samples were analyzed within 4 hours of collection

Parameters:
Pulse
Blood pressure
Respiratory rate
Peak Expiratory Flow Rate
Oxygen saturation
4.8. Treatment protocol:
After carrying out initial assessment, selected patients
were divided into the following groups:

4.8.1. Group A:
Patients received conventional treatment of 0.5 ml of
Salbutamol (2.5 mg) by neublizer and oxygen therapy,
followed by 100 mg of Hydrocortisone intravenously.

4.8.2. Group B:
Besides conventional treatment as in group A received after 30
minutes, a dose of Intravenous magnesium sulfate 25 mg per Kg
body weight or maximum 2 g diluted in 100 ml of normal
saline in 20
minutes.
Administration of drugs in the both the groups were monitored
by pulse oxymetry. After a period of 60 and 120 minutes vital
signs, pulse oxymetry and Peak Expiratory Flow Rate (PEFR)
were again recorded for the patients in both the groups.
5. Statistical analysis:

The data were evaluated in statistical program SPSS


versions 16.0. Categorical parameters such as Gender,
Age groups etc. were presented as n(%). Numerical
variables like Age in years, Duration of asthma, Pulse
Rate, Respiratory Rate, Systolic and Diastolic Blood
Pressure, Oxygen Saturation, Peak Expiratory Flow
Rate etc. were presented as Mean + Standard
Deviation and Student t test (2 tailed) was applied to
compare the means among the Conventional and
Magnesium). All the data were calculated on 95%
confidence interval. A P value < 0.05 was considered
as statistically significant level for all the comparisons.
RESULTS
Table No. 1TABLE NO. 7

COMPARISON OF RESPIRATORY RATE (BREATHS / MINUTES)


BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

(n = 73)

Respiratory rate
(breaths / Conventional Magnesium
P value
minutes) (n = 36) (n = 37)

Before 32.6 + 4.84 33.7 + 5.41 0.36

After 60 minutes 28.7 + 6.03 26.5 + 3.89 0.06

After 120 minutes 21.1 + 2.95 17.9 + 2.02 < 0.001*

Results are expressed as Mean + Standard deviation calculated by student


t test

* P value is statistically significant


RESULTS
Graph No. 1

COMPARISON OF RESPIRATORY RATE (BREATHS / MINUTES)


BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)
P = 0.36

P = 0.06

P = <0.0001
RESULTS
Graph No. 2
GRAPH NO. 7

COMPARISON OF RESPIRATORY RATE (BREATHS / MINUTES)


BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

(n = 73)

Comparision of Respiration Rate Base line after 60


& 120 min of treatment

42
Respiration Rate

37
32 Conventional
27 Magnesium
22
17
12
30 60 120
(Time M inutes)
RESULTS
TABLE NO. 8
Table No. 2
COMPARISON OF OXYGEN SATURATION
BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

(n = 73)

Conventional Magnesium
Oxygen saturation (n = 36) (n = 37) P value

Before 94.2 + 1.81 93.7 + 2.23 0.23

After 60 minutes 94.6 + 1.60 94.5 + 1.77 0.85

After 120 minutes 95.2 + 1.20 96.2 + 1.51 0.004*

Results are expressed as Mean + Standard deviation calculated by student t


test

* P value is statistically significant


RESULTS
Graph No. 3
COMPARISON OF OXYGEN SATURATION
BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

P = 0.004

P = 0.85
P = 0.23
RESULTS

GRAPH NO. 4

COMPARISON OF OXYGEN SATURATION


BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)
(n = 73)
Comparsion of Oxygen Saturation Base Line,
after 60 & 120 min of treatment

99
97
Oxygen Saturation

95
Conventional
93
Magnesium
91
89
87
85
30 60 120
(Time Minutes)
RESULTS
TABLE NO. 9
Table No. 3

COMPARISON OF PEAK EXPIRATORY FLOW RATE (L/MINUTE)


BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

(n = 73)

Conventional Magnesium
PEFR (L/minute) P value
(n = 36) (n = 37)

Before 164.3 + 34.25 174.0 + 35.54 0.23

After 60 minutes 183.1 + 34.25 206.2 + 37.81 0.008*

After 120 minutes 205.2 + 36.76 237.0 + 43.83 0.001*

Results are expressed as Mean + Standard deviation calculated by student t


test
* P value is statistically significant
RESULTS
Graph No. 5
COMPARISON OF PEAK EXPIRATORY FLOW RATE (L/MINUTE)
BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT
(n = 73)
P = 0.001

P = 0.008

P = 0.23
RESULTS
GRAPH NO. 11
Graph No. 6

COMPARISON OF PEAK EXPIRATORY FLOW RATE (L/MINUTE)


BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

(n = 73)

250

230
Peak Expiratory

210 Conventional
190 Magnesium

170

150
30 60 120
(Time Minutes)
RESULTS
TABLE NO. 10
Table No. 5
COMPARISON OF PULSE (HEART RATE/MINUTE)
BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

(n = 73)

Conventional Magnesium
Pulse Rate (beats /minutes): (n = 36) (n = 37) P value

Before 108.7 + 19.83 109.9 + 17.48 0.91

After 60 minutes 123.2 + 16.86 104.8 + 15.40 < 0.001

After 120 minutes 91.9 + 8.46 88.3 + 5.11 0.04

Results are expressed as Mean + Standard deviation calculated by student t


test
* P value is statistically significant
RESULTS
GRAPH NO. 12

Graph No. 7
COMPARISON OF PULSE RATE (HEART RATE/MINUTE)
BASELINE, AFTER 60 & 120 MINUTES OF TREATMENT

(n = 73
P = < 0.0001
P = 0.91

P = 0.04
RESULTS
Graph No. 8GRAPH NO. 13

COMPARISON OF PULSE RATE (HEART RATE/MINUTE) BASELINE,


Comparision
AFTER 60 & 120of Pulse OF
MINUTES Rate b/w Conventional &
TREATMENT

(n = 73)
Magnesium Group @ 0, 60 & 120 min

190

170

150
Pulse Rate

Conventional
130
Magnesium
110

90

70
30 60 120
(Time Minutes)
DISCUSSION

 In the present study, the mean age was similar to


the study of Silverman RA et al.(Silverman RA,
Osborn H et al.2002)
 The duration of asthma in this study was also
similar to the study of Aggarwal P et al.(Aggarwal
P, Sharad S et al.2006)
 Mean serum magnesium level in this study is
comparable with the study of Silverman RA et al.(
Silverman RA, Osborn H et al.2002).
DISCUSSION

 The heart rate in the baseline and after 60 minutes


of treatment in this study was insignificant in both
the groups and Aggarwal P, Sharad S et al.2006 as
well found same observation in their study. In the
present study, the heart rate after 120 minutes was
significantly slowed down to 88.3 + 5.11 (beats
/minutes) in the magnesium group (n = 37) and it
remained 91.9 + 8.46 (beat / minutes) in the
conventional group (n = 36). These results are
similar to the study of Aggarwal P, Sharad S et
al.2006.
DISCUSSION
 Respiratory rate was significantly reduced in the magnesium
group after final treatment. Mean respiratory rate + SD in
baseline was 32.6+4.84 breaths / minute in the conventional
group and 33.7 + 5.41breaths / minute in magnesium group.
After final treatment, mean respiratory rate + SD were 21.1
+ 2.95 breath / minute (n = 36) and 17.9 + 2.02 breaths /
minute (n = 37) of conventional and magnesium groups
respectively. This finding was comparable with study of Bijani
K et al. 2002, in whose study the average of respiratory rate
in baseline was 34 breaths / minute in the magnesium group
and 35 breaths / minute in the saline group. After final
treatment the respiratory rate declined to 24 breaths/minute
in the magnesium group and 30 in the saline group.
DISCUSSION
 In this study, the baseline average of PEFR were 174.0
and 164 L/minute in the magnesium (n = 37) and
conventional groups respectively. After 60 minutes of
treatment, the mean + SD in conventional
(nebulization) and intravenous magnesium plus
nebulization conventional were 183.1 + 34.25(n = 36)
and 206.2 + 37.81(n = 37) respectively. Nannini et al. (
Nannini LJ Jr, Pendino JC et al.2000) showed that
compared with a single dose of sabutamol, there was a
great increase in peak flow rate when a single dose of
magnesium sulfate was added to nebulised patient with
salbutamol.
CONCLUSION

 The serious health problem posed by asthma cannot be


overemphasized. Unfortunately it is inadequately diagnosed
and is poorly managed, resulting in a vicious cycle of
morbidity and mortality. Even worse is the fact that a lot of
misconceptions about the illness which are widely prevalent
even among health professionals.

 A single dose of intravenous magnesium sulfate and


conventional therapy (by oxygen inhalation, ventoline
nebulization, and intravenous hydrocortisone) administered
to patients with severe acute asthma has been observed to
be effective in relieving the symptoms as compared to
conventional therapy alone.
RECOMMENDATIONS
 Education of patient is important as regards current asthma
management
 Patients should understand their disease process, use of
medications, ability to react to their change disease symptoms, or
actual measured peak flow
 Peak flow meter must be available in all the clinics and emergency
departments and all patients be provided their instruments on
subsidized rates.
 Doctor or nurses should be encouraged to use peak flow meter.
 In for flung areas of countries, physicians, should be encouraged
to use ½ MgSO4 besides conventional treatment
 Mechanical verifications be made available at least at Taluka and
RHC level.
 Patients of asthma be registered and drug companies be instructed
to provide medication on reduced rates for poor patients
 Asthma society Hyderabad Chapter may be activated.
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PROFORMA
Demographic details:
S. No: Name of Institution / Hospital:

Name: Age: Sex: 1. Male 2. Female

Occupation:

Address:

Marital status: Religion:

Date of admission: Ward:

Reg: No. Bed No:

Brief history:
Weight (Kg):
Height:
Duration of Asthma (in years):
Number of previous hospitalizations:
Time of arrival:
Hospital stay:

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